What is an exception request?
If a prescription drug that you need is not on your Medicare Part D plan’s approved list of prescription drugs, or is in a higher-cost tier, you can file a formal written exception request to Medicare, asking that the drug be approved or that the cost of the drug be lowered. The plan must respond to an exception request within 24 hours if it was an expedited request, or within 72 hours if it was a standard exception request.
- If the drug isn’t on the plan’s formulary at all (meaning it’s normally not covered by the plan), a formulary exception request can be submitted. The patient’s medical provider will need to submit information explaining why the non-formulary medication is necessary for the patient, and why none of the medications on the plan’s formulary will adequately treat the patient’s condition.
- If the drug is covered by the plan but in a non-preferred tier (resulting in higher out-of-pocket costs), a tiering exception request can be submitted. The patient’s medical provider will need to submit information explaining why the plan’s preferred drugs (in a lower tier, and thus with lower out-of-pocket costs) would not be as effective for the patient or would potentially harm the patient.
An exception request can also refer to the process of asking a Medicare Advantage plan to cover an out-of-network provider when the in-network options are inadequate. This can include, for example, situations in which there are no in-network providers within a certain time/distance from the patient’s home.
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